Age and Ageing

BackgroundDementia diagnoses are captured across multiple routine data sources, but discrepancies between these may affect care and research. This study determined the prevalence and overlap of recorded dementia across primary care, hospital, and community prescribing data sources in a UK regional cohort, and examined whether outcomes differed by the setting in which dementia was first recorded. MethodsRetrospective cohort study of adults [&ge;]65 years (n=133,407) in a large Scottish health board. Dementia diagnoses recorded from 01/04/2016 to 01/04/2020 were identified across linked primary care, hospital discharge, and prescribing records. Associations between source of first recorded dementia diagnosis and subsequent mortality and emergency hospitalisation were estimated using Cox proportional hazards and Fine-Gray competing risks models. ResultsAt baseline (01/04/2016), 7544/133407 individuals (5.7%) had recorded dementia: 95.1% in primary care, 73.3% in hospital, and 54.3% in prescribing records. Over four years, 7359 of the remaining 125,863 individuals (5.8%) had newly recorded dementia: 70.2% in primary care, 22.2% in hospital, and 7.6% in prescribing records. Only 35.9% of hospital-recorded diagnoses were coded in primary care records within a year. People first diagnosed in hospital were older, more frail, more socioeconomically deprived, and had higher mortality than those first diagnosed in primary care (<30days: adjusted Hazard Ratio (aHR) 8.96, 95%CI 6.94-13.52; >365days: aHR 1.29, 95%CI 1.19-1.41). ConclusionsDementia is variably recorded across routine datasets, and the setting in which dementia is first recorded identifies groups with markedly different prognosis. Improved data source integration and scrutiny of hospital-based diagnostic pathways are needed to ensure diagnoses are reliably transferred and people with dementia receive timely, equitable post-diagnostic care.

Background Older adults' walking has so far been evaluated using standardised assessments of walking capacity within a clinical setting. By taking the evaluation out of the laboratory into the real world, this study provides first evidence of the ability of Digital Mobility Outcomes (DMOs) to detect changes over time and the Minimal Important Difference (MID) in patients after proximal femoral fracture (PFF). This will guide the implementation of DMOs in research and clinical care. Methods For this multicenter prospective cohort study, 381 community-dwelling older adults were included within one year after sustaining a PFF and assessed at two time points, separated by six months. Walking activity and gait DMOs were measured using a single wearable device worn on the lower back for up to seven days. A global impression of change question and three mobility-related outcome measures (Late-Life Function and Disability Instrument; Short Physical Performance Battery; 4m gait speed) were used as anchor variables. To assess each DMOs ability to detect changes, we calculated the standardized mean change as effect size. For estimating MIDs, both distribution-based and anchor-based methods were applied, followed by triangulation by experts if at least three anchor-based estimates were available per DMO, resulting in single-point estimates. Results All three anchor variables demonstrated substantial changes. Overall, 10 out of 24 available DMOs showed large and 7 DMOs moderate positive effects in the expected direction of the respective anchors. Seven DMOs showed no or only small effects. For 12 DMOs, at least three anchor-based estimates were available, enabling MID triangulation. MIDs for walking activity DMOs per day were: a walking duration of 10 minutes, a step count of 1,000 steps, 50 walking bouts (WB), and 15 WBs in WBs over 10 seconds. For gait DMOs, depending on the walking bout length, MIDs for walking speed were between 0.04 m/s and 0.08 m/s, and MIDs for cadence between 4 and 6 steps/minute. Almost all DMOs showed a strong ability to detect improvement in mobility, but rarely in detecting decline. Conclusions For the first time, MIDs are presented for real-world DMOs in PFF patients. These MIDs inform sample size requirements and interpretation of intervention effects for clinical trials, thereby providing guidance and reassurance for clinicians and regulatory bodies.

A key societal priority is to support people with dementia and their care partners to live well, particularly through improved access to high-quality information, continuity of care, and consistent post-diagnostic support. The Sage House Model represents a novel, community-based approach to integrated dementia care, co-locating diagnostic assessment, tailored support services, psychosocial interventions, and opportunities for social engagement within a single accessible centre. By reducing fragmentation across health, social care, and voluntary sector provision, the model is designed to address key determinants of living well with dementia. The present study examined whether the Sage House Model is associated with key wellbeing outcomes for both people with dementia and care partners. Using a natural experiment design, outcomes were compared between participants accessing the Sage House centre in Tangmere and those receiving standard care. The sample included 135 people with dementia (Mage = 74.64, SD = 8.30) and 129 care partners (Mage = 67.23, SD = 9.84). A series of ANCOVAs indicated that people with dementia accessing Sage House reported significantly higher quality of life (p = .004, {omega}2 = .06), life satisfaction (p = .004, {omega}2 = .07), and wellbeing (p = .044, {omega}2 = .03) compared with those receiving standard care. In addition, care partners with access to Sage House reported significantly greater needs-based QoL, particularly in relation to improved access to information and support (p = .005, {omega}2 = .07). These findings provide initial empirical support for community-based integrated dementia care in enhancing wellbeing for people with dementia and their care partners, and highlight the value of co-located, multicomponent dementia services in addressing post-diagnostic gaps in real-world care.

BackgroundAntidepressant use is common in people with dementia. Antidepressants may be started to manage symptoms of dementia, rather than depressive and anxiety disorders. We hypothesised people prescribed antidepressants around the time of dementia diagnosis may have different characteristics from those with longstanding prescriptions. MethodsWe used linked primary care (Lambeth DataNet) and specialist (Clinical Record Interactive Search) data for patients with dementia in south London, UK. Antidepressant prescription was ascertained, and a new start was within one year before or after dementia diagnosis. Coded fields, a rating scale for neuropsychiatric symptoms and natural language processing of full-text were used to describe depression and anxiety. ResultsOf 3,713 patients with dementia, 28% were prescribed antidepressants within the year of dementia diagnosis, and 42% of these were new start prescriptions. Compared to the no antidepressant group, the new start group were more likely to be female, have vascular dementia and neuropsychiatric symptoms. Compared to the long-standing group, new start had fewer comorbidities; people from non-White ethnicities were more likely to lack documentation of depression or anxiety. Deprescribing was equally unlikely in new and long-term prescriptions (6.3% vs 5.5% per year of follow-up). ConclusionsThe high incidence of new prescribing, as well as the lack of deprescribing, points to unmet needs and a role for more proactive medication review. Further studies should include the clinician and patient voices to further understand how to improve non-pharmacological support for people at the threshold of dementia.

BackgroundTreatment outcomes and satisfaction improve when healthcare decisions align with patient preferences. However, little is known about general health preferences in older adults, and eliciting patient preferences is time consuming. AimTo describe the distribution of preferences for healthcare in general, and associations between preferences and patient characteristics in adults aged 50 years and over in England. Design and settingData were collected in wave 8 (2016/2017) of the English Longitudinal Study of Ageing (ELSA), a biennial longitudinal survey of people aged 50 and over living in private households in England that began in 2002/2003 and is designed to be nationally representative. MethodData were collected from ELSA participants using face-to-face interviews and a short self completion questionnaire. Amongst other items, the questionnaire contained six new measures of general healthcare preferences: risk aversion, future orientation, quality or length of life, body function compared to looks, openness to experimental treatments, and preference to leave treatment decisions to a doctor. ResultsHealthcare preferences varied substantially, with some systematic patterns by age and sex: women were less likely than men to want to delegate decisions to doctors, and more likely to prioritise quality of life over length of life; participants aged over 75 years were more likely than younger participants to want to delegate decisions to doctors, and more likely to want to avoid risks. ConclusionThe systematic sex and age differences offer a useful starting point for eliciting healthcare preferences in a busy clinical environment, but cannot replace asking about individual preferences.

BackgroundCognitive decline and dementia represent major public health challenges in aging populations. Natural language processing (NLP)-augmented clinical decision support systems (CDSS) offer promising tools for early detection, yet causal evidence on their longitudinal impact at the health system level remains sparse. This study examines whether the phased adoption of NLP-augmented CDSS across German geriatric primary care practices causally improved cognitive decline detection rates over a six-year period. MethodsWe employed a System Generalized Method of Moments (System GMM) estimator, specifically the Arellano-Bover/Blundell-Bond approach, to analyze a dynamic panel dataset comprising 847 geriatric primary care practices across 14 German federal states from 2019 to 2024. The dependent variable was the annual cognitive decline detection rate per 1,000 registered patients aged 65 and older. The key exposure was the intensity of NLP-CDSS utilization, measured as the proportion of clinical encounters with NLP-assisted documentation review. We controlled for time-varying confounders including practice size, physician-to-patient ratio, urbanization, regional deprivation indices, and state-level health expenditure. Instrument validity was assessed using Hansens J-test for overidentifying restrictions and the Arellano-Bond test for serial correlation. ResultsSystem GMM estimation revealed that a one-standard-deviation increase in NLP-CDSS utilization intensity was associated with a 4.73-point increase in the cognitive decline detection rate per 1,000 patients (95% CI: 2.41-7.05, p < 0.001), controlling for persistence in detection rates ( = 0.614, SE = 0.047). The Hansen J-statistic (p = 0.372) confirmed instrument validity, and the AR(2) test (p = 0.489) indicated no second-order serial correlation. Heterogeneity analyses revealed stronger effects in rural practices ({beta} = 6.12, p < 0.001) compared to urban practices ({beta} = 3.28, p = 0.004). The lagged dependent variable coefficient indicated substantial persistence, suggesting that practices with historically higher detection rates continued to outperform, independent of NLP-CDSS adoption. ConclusionsNLP-augmented clinical decision support significantly and causally improved cognitive decline detection rates in German geriatric primary care, with particularly pronounced effects in rural and underserved settings. Dynamic panel data methods accounting for endogeneity and state dependence provide stronger causal evidence than cross-sectional analyses. These findings support the scaled implementation of NLP-based screening tools as a cost-effective strategy for addressing the growing dementia burden in aging populations.

This study challenges the assumption that undiagnosed cognitive impairment (CI) is driven primarily by patient-level barriers like poor awareness. In a population-weighted cohort of 1,856 older Singaporeans, CI prevalence was 24.7% (95%CI 18.8-31.8); yet the undiagnosed rate was high (81.4%, 95%CI 65.6-90.9), especially for mild CI (97.9%, 95%CI 94.1-99.3). This diagnostic gap persisted despite high symptom awareness (81.3%, 95%CI 63.6-91.5) and help-seeking intent (63.3%, 95%CI 47.5-76.7), with informants becoming key as CI worsened. Findings suggest successful public health campaigns have shifted the bottleneck from community awareness to healthcare system capacity, creating an opportunity for a policy shift to meet rising demand for diagnosis--by empowering primary care with efficient case-finding tools, formalizing integrated diagnostic pathways, and establishing channels for family informants involvement. From these findings, we conceptualized a paradox of success model, providing a framework for other health systems to adapt policy as public engagement grows.

ObjectivesCochlear implants are an effective intervention for people with severe to profound hearing loss. However, only a small percentage of those who could benefit from cochlear implants have one. We aimed to understand the barriers to access and receipt of cochlear implants in the UK. DesignMixed-methods study. SettingThe University of Southampton Auditory Implant Service. ParticipantsData on referral route and personal characteristics of 456 patients over the age of 60 at the time of cochlear implantation, who received a cochlear implant before 2020 were included. Semi-structured interviews were held with six people who hear with an implant. Primary Outcome MeasuresDemographic factors and routes of referral for cochlear implantation for older adults who went on to receive an implant. Semi-structured interviews were designed to identify key motivators and barriers to receiving a cochlear implant. ResultsSex and ethnicity did not affect cochlear implant uptake, whereas socioeconomic status and differences in referral pathways were associated with differences in uptake. People from lower socioeconomic groups were underrepresented in the implanted population at USAIS. Certain health providers across the cohort catchment area were more likely to refer patients than others which in turn affected cochlear implant uptake. Barriers to uptake were poor knowledge about implants by patients and clinicians, and fear of surgery. A willingness by patients to explore a way to reduce the daily challenges associated with hearing loss and the support and encouragement of clinicians, family and friends and other people with implants were motivators to implant uptake. ConclusionThese findings will inform future research to address the key factors preventing eligible individuals from receiving cochlear implants. This will support the development of strategies to improve access to, and uptake of, cochlear implants for older adults. ARTICLE SUMMARYO_ST_ABSStrengths and limitations of this studyC_ST_ABSO_LIStrength: Mixed-methods approach was used: O_LIA service evaluation where we analysed retrospective data from 456 patients from a UK cochlear implant centre. C_LIO_LISemi-structured interviews were used to gather rich qualitative data for a deeper insight into the barriers and motivators of cochlear implant uptake. C_LI C_LIO_LILimitation: Data from patients that were referred to USAIS but did not receive cochlear implants was not included. C_LIO_LILimitation: Sample size for interviews was small (six participants) due to time constrains of the (student) project. C_LI

IntroductionAlzheimers disease (AD) prevalence rises with societal ageing. In clinical care, behavioral and psychological symptoms of dementia (BPSD)--including depression, agitation/aggression, apathy, and sleep disturbance--worsen patients quality of life and substantially increase caregiver burden, more significantly than the cognitive symptoms. Standard BPSD assessments rely on caregiver-rated questionnaires that are cross-sectional and may be biased when caregivers are themselves older adults. Device-based measures (e.g., research-grade wrist actigraphy) can provide objective longitudinal data and novel features. In parallel, therapeutic wearables may improve sleep and mood in adults, and might improve BPSD if accepted by people living with dementia. This study aims to assess the feasibility and acceptability of two wearables (Geneactiv actigraphy and Re-Timer circadian regulator) among AD patients with significant BPSD and their caregivers in Taiwan. MethodsThis dyadic pilot study will recruit 20 participants (n=10 AD patients; n=10 caregivers) from outpatient services and affiliated day-care/dementia hubs in rural Taiwan. Participants will wear Geneactiv continuously for 8 weeks and Re-Timer [&ge;]30 min/day for 4 weeks. Device-based data will be processed with GGIR, a well validated R-package designed for processing accelerometer data. Questionnaire assessments include Pittsburgh Sleep Quality Index, PSQI (PSQI), Neuropsychiatry Inventory Questionnaire (NPI-Q), Caregiver Burden Inventory (CBI), and a semi-structured interview based on the Taiwanese version of Quebec User Evaluation of Satisfaction with Assistive Technology (T-QUEST) at prespecified timepoints. DiscussionWearable devices may facilitate the measurement and treatment of specific BPSD, as well as reduce caregiver burden. If proven feasible even in rural Taiwan where both digital and health literacy and resources are limited, this model will inform how device-based dementia care model can be considered and applied in the context of global ageing. Ethics & registrationThis protocol has been approved by the China Medical University and Hospital Research Ethics Committee (CMUH114-REC3-072), and pre-registered in ClinicalTrials.gov (NCT07249918).

BackgroundDementia affects over 57 million people worldwide. UK and international policy position personalised, conversation-based care planning as central to post-diagnostic support. However, delivery in primary care is inconsistent, and many practitioners lack dementia-specific communication training. Existing evidence focuses on single roles or settings, leaving a gap in understanding how communication operates across the primary care workforce. AimsTo identify what helps and hinders effective communication for integrated dementia care planning and determine the support and training needs of the wider primary care workforce. MethodsO_LISemi-structured interviews - 11 people with dementia, 13 family carers, and 19 primary care practitioners from diverse roles, exploring experiences of care planning conversations C_LIO_LIReflexive thematic analysis C_LI ResultsThree themes were developed, progressing from micro-level communication practices (Theme 1: Beyond the tick-box), through triadic dynamics (Theme 2: Balancing voices in the conversation), to organisational influences (Theme 3: From silos to meaningful shared care planning). Time and Conversation as intervention cut across all themes, shaping trust and disclosure. Participants reported reliance on tick box approaches, inconsistent preparation, and uncertainty about care plan purpose and ownership. Non-clinical roles were commonly viewed as well placed to support meaningful conversations, but were often described as constrained by unclear remit and weak integration. ConclusionsA persistent gap remains between policy ambitions and everyday practice. Time-pressured, checklist-driven encounters and fragmented systems undermine shared decision-making. The expanded primary care workforce offers untapped potential to address these gaps, but this requires clearer roles, formal integration, and targeted investment in communicative skills.

IntroductionIn Canada, older adults face barriers to access healthcare, which includes falls prevention. An effective option to improve access is telehealth, which may be used for falls risk screening remotely. However, reliability and validity of remote functional mobility assessment have yet to be established within a francophone older adult context. This study aimed to assess the reliability and validity of the Timed Up and Go and the Five Times Sit to Stand when administered remotely and determine whether remote assessments could serve as a valid and reliable alternative to in-person fall risk screening for francophone older adults. MethodsThe TUG and FTSTS were conducted remotely by physiotherapists and in-person by individuals with varied healthcare backgrounds. Inter-rater reliability was examined between two remote assessors and between one remote compared to one in-person assessor. Concurrent validity was examined between in-person and simultaneous remote assessments. ResultsSixty-seven older adults completed assessments either with an in-person and a remote assessor or two remote assessors. Excellent inter-rater reliability was documented for both the TUG and FTSTS remotely and in-person. Concurrent validity was also excellent, with complete agreement between remote and in-person assessors for correctly identifying participants at risk of falls. DiscussionRemote mobility assessments can be conducted safely and with excellent reliability, providing an effective alternative to in-person falls screening in a preferred language. Remote assessments can be used in the context of falls prevention programs to improve access and health equity for older individuals who face mobility, geographic or linguistic barriers.

IntroductionBecause hearing difficulties contribute significantly to years lived with disability and global economic burdens, finding ways to support hearing health is crucial. Despite decades of research investigating hearing loss and why some listeners struggle while listening to speech in noise more than others, answers remain elusive. Investigating modifiable lifestyle factors such as moderate-to-vigorous physical activity (MVPA) that have been shown to support brain and cognitive function may help answer these questions about hearing health. MethodsWe examined the association between time spent in MVPA and self-reported hearing problems in the UK Biobank, a comprehensive population dataset. A subset of 79,286 participants aged 39-70 years who had complete accelerometer, hearing, demographic, and medical data were used. In our sample, 54.57% were female. The duration of MVPA and proportion of participants meeting physical activity guidelines (>150 minutes of moderate-to-vigorous physical activity per week) were measured using wrist-worn accelerometry. Self-reported problems with hearing or understanding speech in noise were the primary outcomes. Logistic regressions were used to assess the relationship between MVPA and hearing problems while controlling for health and demographic factors. ResultsSpending more time in MVPA was associated with lower odds of reporting a hearing problem (OR=0.990, 95% CI [0.983, 0.997], p=0.005) and lower odds of reporting a speech-in-noise problem (OR= 0.991, 95% CI [0.985, 0.998], p= 0.007). Additionally, meeting physical activity guidelines was associated with lower odds of reporting problems with hearing (OR= 0.958, 95% CI [0.923, 0.995], p= 0.025) and speech in noise (OR= 0.953, 95% CI [0.922, 0.986], p= 0.005). ConclusionsThese findings suggest that spending more time in moderate-to-vigorous physical activity benefits hearing health as it is associated with lower odds of reporting hearing or speech-in-noise problems. Targeting physical activity as a non-invasive and low-cost intervention may make the common issue of hearing loss more manageable. Key MessagesWhat we already know: O_LIDecades of research has shown that moderate-to-vigorous physical activity benefits cognitive and brain health. Similarly, prior work has shown that speech in noise understanding relies on executive functions and hearing sensitivity relates to physical activity levels. While the link between these concepts loosely exists, insufficient work has looked at how MVPA affects overall hearing health. C_LI What this study adds: O_LIIn this prospective cohort study of 79,286 participants from the UK Biobank, we used logistic regressions to see whether spending more time in moderate-to-vigorous physical activity was associated with lower odds of reporting problems with hearing or understanding speech in noise. C_LI How this study might affect research, practice, or policy O_LIEstablishing the relationship between moderate-to-vigorous physical activity and overall hearing health can inform future interventions that aim to combat the decline in hearing that comes with age. C_LI

BackgroundThere is growing consensus regarding the multidimensional nature of frailty and the need for comprehensive approaches to its assessment. However, existing assessment instruments have shown limited validity evidence or failed to adequately cover all the proposed theoretical dimensions of frailty. To address this gap, we recently developed the preliminary items of the Multidimensional Frailty Scale (MFS), a new instrument aimed to assess physical, cognitive, affective, social, and environmental frailty in older adults. This study sought to determine the final item set and to evaluate the psychometric properties of the final version. MethodsWe conducted a cross-sectional observational study with 283 individuals aged 65- 98 years. Participants completed the preliminary 51-item version of the MFS, the Tilburg Frailty Indicator (TFI), and a sociodemographic questionnaire. Item selection was guided by corrected item-dimension correlations, standardized factor loadings and content validity considerations. We examined dimensionality using confirmatory factor analysis comparing a unidimensional model and a five-factor second-order model, assessed internal consistency with Cronbachs alpha, and evaluated convergent validity through Spearman correlations between analogous dimensions of the MFS and the TFI. ResultsItem analysis yielded a final 29-item version of the MFS. The five-factor second-order model demonstrated excellent fit to the data, whereas the unidimensional model showed poor fit. Internal consistency was high for all dimensions and for the total scale. Convergent validity was supported by moderate-to-large correlations between corresponding MFS and TFI dimensions. ConclusionsThe MFS demonstrates robust psychometric properties and provides a brief yet comprehensive instrument to assess multidimensional frailty in older adults. Its hierarchical structure allows both global and domain-specific assessment, supporting more precise identification of frailty profiles. The ease of administration facilitates its use in research and clinical practice. Further validation in diverse linguistic and cultural contexts may enhance its applicability and support cross-national comparative research on multidimensional frailty.

BackgroundThis study used qualitative methods to test and refine a framework for educating cognitively unimpaired individuals about their individual risk for Alzheimers disease and related dementias (ADRD) and intrapersonal health belief factors as part of the TEACH (Tailored Education for Aging and Cognitive Health) intervention. MethodWe assessed individuals ADRD risk factors and health belief concepts. Personalized data were presented individually, followed by a semi-structured phenomenographic interview. Applied thematic analysis was used to identify representative statements, trends, and differences. ResultsIn N=11 individual interviews with middle-aged and older participants (ages 49-69; 45% women), participants had generally positive experiences of learning their personal dementia risk; the information was perceived to be unsurprising and occasionally consoling. They demonstrated a good understanding of the health belief concepts, including identifying relationships between intrapersonal health beliefs and health behaviors. Participants provided feedback on the visual aids and methods of conveying health belief information. ConclusionsWe used qualitative data from individual interviews to refine an explanatory framework for educating individuals about their personalized risk for ADRD and intrapersonal health beliefs that may be barriers or facilitators of health behavior change. The refined TEACH intervention is designed to promote long-term maintenance of target health behaviors in middle-aged adults to mitigate ADRD risk.

ObjectivesTo characterize contemporary pharmacologic treatment patterns for Alzheimers disease and related dementias (ADRD) among U.S. long-term care residents and to examine facility- and resident-level factors associated with treatment. DesignRetrospective, observational study. Setting and ParticipantsElectronic health record data from 1,675,873 long-term care residents in the PointClickCare Life Sciences database included 359,801 with a documented ADRD diagnosis in skilled nursing facilities in the U.S. (January-April 2025). MethodsResidents were classified as treated/untreated based on receipt of guideline-directed ADRD therapy, consistent with Alzheimers Association guidelines. Analyses incorporated demographics, comorbidities, medication burden, and facility characteristics. Multivariate logistic regression estimated odds of receiving guideline-concordant therapy. ResultsOverall, 72.5% of residents with ADRD received [&ge;]1 pharmacologic treatment recommended for ADRD. Treatment was most common among residents with Lewy body dementia (83.9%) and early-onset Alzheimers disease (82.3%) and least frequent among residents aged [&ge;]90 years (65.1%), Black/African American residents (66.8%), and those with cerebral degeneration (66.8%). Treated residents exhibited higher medication burden (mean 4.4 vs 3.3). Diagnoses for other chronic conditions as well as specific ADRD subtypes strongly impacted probability of treatment; diabetes and hyperlipidemia were associated with lower odds of treatment, whereas ADRD subtypes strongly predicted treatment. Conclusions and ImplicationsMore than one-quarter of residents with ADRD remain untreated with guideline-recommended pharmacotherapy, and treatment varied significantly by non-clinical predictors. These findings underscore the need to investigate and understand possible treatment disparities, optimize polypharmacy management, and discover new ADRD treatments, as current options are often ineffective with many side effects. Brief SummaryThis study used real-world data from electronic health records (EHR) to understand treatment patterns of those with Alzheimers disease and related dementias (ADRD) in U.S. long-term care facilities. International Classification of Diseases Tenth Revision, Clinical Modification (ICD-10) codes were used to identify ADRD diagnoses and medication orders were used to identify treatment. From January to April 2025, there were 359,801 with a documented ADRD diagnosis in skilled nursing facilities. Over 25% of those with ADRD did not have a medication order for a guideline-recommended pharmacological treatment. Comorbidities of diabetes and hyperlipidemia were associated with lower odds of receiving ADRD treatment, suggesting concerns related to adverse drug reactions and competing clinical priorities. The use of cognitive and disease-modifying therapies was low compared to behavioral/psychiatric medications; this finding suggests a need for more effective and safe drugs that target the root causes of ADRD opposed to the behavioral and psychiatric complications. Taken together, the results of this study call for targeted interventions to address disparities in treatment, enhanced clinical decision-making support regarding polypharmacy, and improved pharmacological options for those with ADRD.

INTRODUCTIONAgitation is a common and burdensome neuropsychiatric symptom in dementia that fluctuates from day to day, but objective tools for short-term risk stratification are limited. We examined whether nocturnal physiological signals from unobtrusive under-mattress sensors predict next-day daytime agitation and whether associations differ for agitation occurrence versus severity. METHODSWe extracted cardiorespiratory, movement, and sleep-proxy features from two long-term care cohorts (N=55; 333 nights) and one external home-monitoring cohort (N=18; 803 nights). A two-part mixed-effects framework was used to model next-day agitation episodes. RESULTSLower nocturnal respiratory rate and greater activity instability independently predicted higher odds of next-day agitation occurrence. Associations were stronger for motor than verbal agitation. Respiration-related predictors were validated externally. Conversely, no nocturnal features significantly predicted agitation severity. DISCUSSIONPassive sleep monitoring identified reproducible, physiologically interpretable markers of next-day agitation occurrence, supporting the potential of under-mattress sensing for short-term risk stratification and more proactive dementia care.

BackgroundReactive balance training using repeated perturbations may reduce falls, however, training methods are not easily replicated or translatable to clinical settings. This study aimed to examine the effects of a novel reactive balance training program on balance recovery from laboratory induced trips and slips and fall risk factors in older people using simple and low-cost equipment. MethodsWe conducted a randomised controlled trial involving 88 older people. An intervention group (n = 43) received the ReacStep program which involved tether-release reactive stepping and intentional slips once a week for 6 weeks. Both the intervention and control (n = 45) groups received home-based strength training for 8 weeks. Blinded staff assessed reactive balance (laboratory induced falls), physical functions at baseline (week 1) and post intervention (week 8). Weekly SMS surveys ascertained falls in daily life over 12 months. ResultsBoth groups were comparable in demographics, with a mean age of 72 years (SD = 5.6). Adherence to ReacStep sessions was high (90%). There were no significant differences between groups in laboratory-assessed reactive balance falls at post-test or daily-life falls over one year (P =.19). However, at post-test, the intervention group demonstrated significant improvements in usual gait speed, maximum step length, and choice stepping reaction time compared to controls (P <.05). ConclusionsThe ReacStep program demonstrated excellent adherence, was well tolerated, and improved gait parameters required for balance recovery following postural perturbations in older people. Nevertheless, it appears this program is not sufficient to improve reactive balance against unexpected trips and slips. Key pointsO_LIThe ReacStep program is acceptable, demonstrates excellent adherence and improves gait measures in older people, potentially reducing fall risk. C_LIO_LIThe generalisability against unexpected trips, and slips, and falls in daily life may be limited. C_LIO_LIFuture research should explore more ecological perturbations while maintaining its accessibility and acceptability. C_LI

Gait variability is a critical functional indicator of dynamic balance and neurocognitive decline in health. Its translation into clinical practice is, however, challenged by a lack of age-related normative trajectories and reference values under real-world ecological settings. Furthermore, the conventional metrics used to estimate gait variability (Coefficient of Variation, CV; Standard Deviation, SD) have a fundamental methodological flaw: the inherent sensitivity of conventional metrics to the statistical outliers and environmental noise in real-world walking. In this study, we mitigate this factor by applying a robust statistical framework to quantify gait variability. Analysing a large-scale cohort of community-dwelling older adults (n=2,193), we first demonstrate that free-living gait data follows a heavy-tailed distribution, necessitating the use of robust estimators like the Robust Coefficient of Variation (RCV-MAD) and Median Absolute Deviation (MAD). Leveraging these metrics, we established the normative trajectory and reference values of real-world gait variability across the ageing lifespan, revealing a distinct, age-dependent increase in spatio-temporal fluctuations, indicating a decline in rhythmicity and steadiness with age. We further demonstrated the clinical utility of these robust metrics: RCV-MAD consistently yielded larger effect sizes than conventional CV in discriminating between fallers and non-fallers across all gait parameters. Furthermore, we illustrate the potential of long-term unsupervised monitoring to capture intrinsic variability during real-world walking. Validated for consistency and reliability, this robust framework provides the necessary ecological validity to transform gait variability into a standardised, rapid clinical metric for assessing functional decline at an early timepoint.

BackgroundHip fracture remains a leading cause of morbidity and mortality among older adults in the United States. The aim of this systematic and meta-analytical review is to synthesize available evidence on predictors of one-year mortality following hip fracture among older adults, guided by a socio-ecological framework. MethodsWe searched PubMed, Embase, Web of Science, CINAHL, and Scopus for U.S.-based studies published between 2010 and 2025 reporting one-year mortality after hip fracture. Studies were included if they evaluated predictors of mortality across pre-injury, perioperative, or post-discharge phases. Data were extracted on study design, population characteristics, mortality outcomes, and risk factors. Predictors examined in [&ge;]3 studies were pooled using random-effects meta-analysis, and narrative synthesis was conducted for predictors with limited data. Methodological quality was assessed using the Joanna Briggs Institute checklist. ResultsTwenty-eight studies (n = 835,226) met inclusion criteria. Pooled one-year mortality was 21.8%, ranging from 7.1% to 54.4%. Advancing age and male sex were consistent non-modifiable risk factors. Comorbidity burden, including congestive heart failure, chronic kidney disease, myocardial infarction, and dementia, and measures of frailty and functional impairment were among the strongest predictors, often doubling mortality odds. Perioperative factors such as higher injury severity and delayed surgery, and post-discharge factors including hospital readmission, missed follow-up visits, and postoperative complications, were also associated with increased mortality. ConclusionOne-year hip fracture-related mortality remains high and stems from multifactorial causes. A multi-level, systems-oriented approach may be necessary to meaningfully reduce long-term mortality in this growing and vulnerable population.

BackgroundWhen creating risk prediction models for time-to-event data, methods that incorporate time are typically used. Random survival forests (RSF), an extension of random forests (RF), are one such class of models. We compared RSF to RF in the context of time-to-event outcomes in the ASPirin in Reducing Events in the Elderly (ASPREE) randomized controlled trial. We hypothesize that RSF will have superior discrimination and calibration versus RF. MethodsParticipants from ASPREE residing outside the US or with missing data were excluded. A total of 2,291 participants were assigned 1:1 into training and test sets. RF and RSF models were trained using a total of 115 measures as candidate predictors. The outcome of interest was the earliest of incident dementia, physical disability, or death. ResultsThe primary endpoint occurred in 10.5% of participants. Discrimination was similar between the models: sensitivity ([~]0.75), specificity ([~]0.57), positive predictive value ([~]0.17), time dependent AUC ([~]0.71), and Harrells concordance ([~]0.73). Calibration was likewise similar, Brier score ([~]0.09). DiscussionThe RF and RSF models exhibited comparable discrimination and calibration. We conclude that RSF may not always lead to more accurate predictions of outcomes compared to RF. Further examination in different clinical trial cohorts is needed to better understand the context in which adding time into outcomes risk modeling adds value.